S.H
College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Care Across the Lifespan II
Dr. Elizabeth Connole-Pond
June 21, 2023
Patient ID: G.S.
Date: June 14, 2023
Course: 6675-34
Clinical Faculty: Dr. E. Connole-Pond
Preceptor: E. Anderson, M.D.
Subjective:
CC (chief complaint): “I’m so anxious, that Klonopin they gave me in the ER really helped. Will I be able to get that here?”
HPI:
55-year-old Caucasian divorced male patient; GS was referred to McNew from the AAMC ER after his psychiatric provider sent him to the hospital for what is provider noted were, “severe mania symptoms”. He has been seeing his provider for over 20 years and she was able to provide additional information for this assessment. When corroborating his history, the provider speculated that he was terminated from his job as a secret service agent in 2013 for his role in a serious scandal in the context of a manic episode. Since then, he has been divorced once, remarried, and now is legally separate. As part of the divorce settlement, his home is going to settlement next week which is adding to the significant distress. He reports that anxiety is his chief complaint and other symptoms include “mania”, perseveration, restlessness, and lack of sleep.
Substance Current Use:
Patient denies illicit substances and endorses light social drinking (1-2 drinks a month with friends)
Medical History:
· Current Medications: Effexor 300 mg po Q Day (however patient has deviated from this order and has been taking 150 mg Q am and 150 mg Q HS)
· Allergies: NKDA
- Reproductive Hx: unknown
Family History:
Biological sister with Bipolar I disorder, treated with Lithium
Per patient report, she developed renal disease as a result of the treatment.
ROS:
· GENERAL: Patient is AOx4, well appearing, well nourished, with rapid speech, and pacing during assessment. Denies fever chills.
· HEENT: Normocephalic
· SKIN: Warm, Dry, Intact, negative for bruising or abrasions
· CARDIOVASCULAR: Normal rate and rhythm
· RESPIRATORY: nonlabored breathing
· GASTROINTESTINAL: Negative
· GENITOURINARY: Deferred
· NEUROLOGICAL: Negative
· MUSCULOSKELETAL: gait is coordinated and stead, normal range of motion
· HEMATOLOGIC: negative
· LYMPHATICS: negative
· ENDOCRINOLOGIC: denies heat or cold intolerance, or diabetes
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Appearance, behavior, gait:
Level of alertness: alert
Level of attention: attentive
Cooperation? yes
Grooming: Good
Disheveled: No
Eye Contact: Good
Activity: Psychomotor restlessness, pacing
Abnormal movement No
Gait: Normal
Muscle tone: Normal
Speech & Thought Process:
Rate: rapid
Articulation: normal
Spontaneity: normal
Volume: normal
Rhythm: Normal
Language:
Naming good normal
Repeating normal
Associations and Thought Processes:
Associations: Intact
Process: linear, goal directed
FTD: No
MOOD, AFFECT, VITAL SENSE, SELF ATTITUDE, AND RISK ASSESSMENT:
Anxious, perseverative, decreased self-worth, vital sense moderate
(High vital sense looks like: remarkable energy, liveliness, or force of personality. Low vital sense looks like decreased attentiveness to work tasks, decreased energy), decreased mental energy.)
Sleep: poor
Appetite: poor
Concentration: fair
Hope: poor
Pleasure capacity: diminished
SI/PDW: denies
Plan: denies
Access to means: has guns at home (former law enforcement)
HI/VI: denies
Plan: denies
Perceptual disturbances: denies
Hallucinations: denies
THOUGHT CONTENT:
+perseverations, anxiety
JUDGMENT: fair
INSIGHT: fair
INTELLIGENCE: appropriate for education and developmental stage
COGNITIVE MMSE? Oriented, attentive, good memory, fair concentration
Diagnostic Impression:
1. Bipolar I Disorder, [F31.12] moderate, current presentation manic, with anxious distress
2. Rule out Bipolar with mixed features: Rationale- patient demonstrates manic episode with prominent dysphoria but does not yet demonstrate diminished interest in all activities, psychomotor retardation, loss of energy, or recurrent thoughts of death. However, DSM-V-TR note that patients who display both mania and depression at the same time should be listed as manic episode, with mixed features due to severity (APA, 2022.)
3. Rule out panic disorder: Rationale – DSM-V-TR suggests that a careful list of symptoms can reveal behavior is a result of a panic disorder
4. Rule out Generalized Anxiety Disorder: Rationale-DSM-V-TR warns that anxious ruminations can be mistaken for manic racing thoughts (APA, 2022.)
G.S. appears to be a reliable informant with sincere motivation to relieve his symptoms by seeking out professional help for anxiety in the presence of a manic episode. Observable symptoms of mania include poor sleep, restlessness, pacing, wide affect, and speech that is rapid, pressured, and perseverative. He rates current anxiety “8 out of 10” and denies SI/HI/PDW/AH/VH on assessment. Brief psychotherapy was offered with medication education regarding benzodiazepine risks, and proper way to take his current Effexor prescription to avoid sleep disruption by taking all 300 mg in the morning. Pharmacological education was also given regarding risks, benefits, and therapeutic value of adding Seroquel 50 mg po Q HS and titration to therapeutic level. Patient was provided ample time for questions, verbalized understanding and is agreeable to this treatment plan. The DSM-V-TR criteria for Bipolar I are met with a history of at least one prior manic episode that lasted longer than a week with elevated, expansive mood, grandiosity, decreased need for sleep, increased goal oriented sexual activity, and risk taking with serious consequences causing severe consequences to his job and marriage (APA, 2022.) He has a history of mostly depressive episodes over more than 20 years of his life as stated by his outside provider with at least one manic episode in his history.
Case Formulation and Treatment Plan:
G.S. will benefit from inpatient behavioral health stay for medication adjustments, individual brief psychotherapy, milieu and OT group therapy this admission stay. Discharge planning includes setting follow-up psychotherapy and medication management with patient at his current outside provider prior to discharge.
Medication Plan:
- Effexor (venlafaxine) 300 mg po Q Day in the morning
- Add Seroquel (quetiapine) 50 mg po Q HS, which will be titrated to therapeutic dose.
Reflections:
Medication rationale: What I learned
Venlafaxine is a serotonin and norepinephrine reuptake inhibitor (SN-RI) and is not a first line treatment for Bipolar I disorder. Boland et al. (2022) suggest the first line approach to treatment is Lithium with an augmenting agent as needed (e.g., antidepressants, antipsychotics, benzodiazepines, and anticonvulsant mood stabilizers). This is supported by evidence from current guidelines listing second generation antipsychotics (SGAs), lithium, and valproate as gold standard psychopharcological therapy in adults (Kishi et al., 2022.)
S.G.’s outside provider has been successfully treating him “off label” with Effexor for over 20 years with success. The rationale for selecting this drug in the first place is not known; however, treatment plans are customized to the specific person using a myriad of factors including provider knowledge, clinical experience, empathy for the patient, and common sense. Collaboration between Dr. Anderson and the outside provider uncovered a long history with this patient. The provider had typically observed a depressive presentation and the SN-RI Effexor had been therapeutic for a significant period of time. G.S.’s provider also informed us that the patient did not want to use Lithium, one of the first-line treatments because his sister had a serious adverse reaction.
There are many factors that cause a Bipolar patient’s presentation to switch from depressive to manic including sudden mood elevation, comorbid panic attacks, and venlafaxine treatment (Niitsu et al., 2015.). This patient has been undergoing a difficult separation, financial concerns, and stress related to selling his home. It is also plausible that the medication caused sleep disruption when the patient took it upon himself to split the 300 mg dose, taking half at night. The inpatient provider understands that in the presence of mania, it is recommended to always have a mood stabilizer when using an antidepressant in Bipolar patients to avoid mania (Niitsu et al., 2015; Vieta, E., 2014). Therefore, given the patient’s current mania with anxious distress, the mood stabilizer, quetiapine works as an appropriate adjunct to quell the acute mania (Stahl, 2021). Interestingly enough, if the patient were presenting with Bipolar II, The American Psychiatric Association Borderline treatment guideline number 3 recommends venlafaxine monotherapy as a second-line treatment (APA, 2021.)
Psychotherapy for Bipolar Disorder
G.S. has been working with his therapist for a significant amount of time. It is not known which school of therapy she is using with the client. Interpersonal and Social Rhythm Therapy is a plausible adjunct treatment to accompany the first line treatment, which is medication (Wheeler, 2022.). This modality addresses three main triggers for a bipolar episode including (1.) stressful life events, (2.) interrupted social rhythm, and (3.) noncompliance with medications. Psychosocial factors disrupt neurochemical changes in the body and changes to circadian rhythms, the culprit of mood changes and insomnia. Interpersonal and Social Rhythm Therapy is usually performed in the individual setting and can sometimes be found in a group format.
Other Adjunctive Treatment Modalities and Health Promotion
The purpose of medication, psychotherapy, and other adjunctive treatment modalities is to prevent further episodes of mania and depression; thus, stabilizing the patient’s mood and improving their quality of life. While medication is intended to correct the current presentation, education should be provided on ways to prevent future problems by using psychoeducation. This writer would educate the patient on the purpose of sleep hygiene, light therapy, and modifying environmental risk factors (Papadimitriou et al., 2007.)
What would you do differently or what would your next invention be?
The patient will be followed by his established provider for further medication management and psychopharmacology treatment. This writer might consider discussing his concerns regarding Lithium further to learn more and educate about ways to safely attempt treatment. As previously stated, the risk of inducing mania is high with Effexor and if the mania is not remedied, the writer would consider discontinuing it in favor of Lamictal augmented by Seroquel (Boland et al., 2022.). An extensive systematic review and meta-analysis of double-blind randomized controlled trials by Kishi et. Al (2022) report that aripiprazole, olanzapine, and risperidone are efficacious in acute bipolar mania.
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
American Psychiatric Association (APA). (2022). Diagnostic and statistical manual of mental disorders (DSM-5-TR). American Psychiatric Association: Washington, DC
American Psychiatric Association (APA). (2021). Should medications with little or no efficacy be prescribed when treating bipolar disorder. Bipolar Disorders, 23(8), 832–833. https://doi.org/10.1111/bdi.13141
Kishi, T., Ikuta, T., Matsuda, Y., Sakuma, K., Okuya, M., Nomura, I., Hatano, M., & Iwata, N. (2022). Pharmacological treatment for bipolar mania: A systematic review and network meta-analysis of double-blind randomized controlled trials. Molecular Psychiatry, 27(2), 1136–1144. https://doi.org/10.1038/s41380-021-01334-4
Niitsu, T., Fabbri, C., & Serretti, A. (2015). Predictors of switch from depression to mania in bipolar disorder. Journal of Psychiatric Research, 66–67, 45–53. https://doi.org/10.1016/j.jpsychires.2015.04.014
Papadimitriou, G. N., Dikeos, D. G., Soldatos, C. R., & Calabrese, J. R. (2007). Non-pharmacological treatments in the management of rapid cycling bipolar disorder. Journal of Affective Disorders, 98(1–2), 1–10. https://doi.org/10.1016/j.jad.2006.05.036
Stahl, S.M. (2021). Stahl’s Essential Psychopharmacology Prescriber’s Guide (7th Ed.). University Printing House: Cambridge, U.K.
Vieta, E. (2014). Antidepressants in Bipolar I Disorder: Never as Monotherapy. AMERICAN Journal of Psychiatry, 171(10), 1023–1026. Retrieved on June 19, 2023, from: https://doi.org/10.1176/appi.ajp.2014.14070826
Wheeler, K. (2022). Psychotherapy for the Advanced Practice Psychiatric Nurse (3rd Ed.). Springer Publishing: New York, NY.
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